Nursing Bullets: Fundamentals of Nursing IV

The implementation phase of the nursing process involves recording the patient’s response to the nursing plan, putting the nursing plan into action, delegating specific nursing interventions, and coordinating the patient’s activities.

The Patient’s Bill of Rights offers patients guidance and protection by stating the responsibilities of the hospital and its staff toward patients and their families during hospitalization.

To minimize omission and distortion of facts, the nurse should record information as soon as it’s gathered.

When assessing a patient’s health history, the nurse should record the current illness chronologically, beginning with the onset of the problem and continuing to the present.

When assessing a patient’s health history, the nurse should record the current illness chronologically, beginning with the onset of the problem and continuing to the present.

Family members of an elderly person in a long-term care facility should transfer some personal items (such as photographs, a favorite chair, and knickknacks) to the person’s room to provide a comfortable atmosphere.

Pulsus alternans is a regular pulse rhythm with alternating weak and strong beats. It occurs in ventricular enlargement because the stroke volume varies with each heartbeat.

The upper respiratory tract warms and humidifies inspired air and plays a role in taste, smell, and mastication.

Signs of accessory muscle use include shoulder elevation, intercostal muscle retraction, and scalene and sternocleidomastoid muscle use during respiration.

When patients use axillary crutches, their palms should bear the brunt of the weight.

Activities of daily living include eating, bathing, dressing, grooming, toileting, and interacting socially.

Normal gait has two phases: the stance phase, in which the patient’s foot rests on the ground, and the swing phase, in which the patient’s foot moves forward.

The phases of mitosis are prophase, metaphase, anaphase, and telophase.

The nurse should follow standard precautions in the routine care of all patients.

The nurse should use the bell of the stethoscope to listen for venous hums and cardiac murmurs.

The nurse can assess a patient’s general knowledge by asking questions such as “Who is the president of the United States?”

Cold packs are applied for the first 20 to 48 hours after an injury; then heat is applied. During cold application, the pack is applied for 20 minutes and then removed for 10 to 15 minutes to prevent reflex dilation (rebound phenomenon) and frostbite injury.

The pons is located above the medulla and consists of white matter (sensory and motor tracts) and gray matter (reflex centers).

The autonomic nervous system controls the smooth muscles.

A correctly written patient goal expresses the desired patient behavior, criteria for measurement, time frame for achievement, and conditions under which the behavior will occur. It’s developed in collaboration with the patient.

Percussion causes five basic notes: tympany (loud intensity, as heard over a gastric air bubble or puffed out cheek), hyperresonance (very loud, as heard over an emphysematous lung), resonance (loud, as heard over a normal lung), dullness (medium intensity, as heard over the liver or other solid organ), and flatness (soft, as heard over the thigh).

The optic disk is yellowish pink and circular, with a distinct border.

A primary disability is caused by a pathologic process. A secondary disability is caused by inactivity.

Nurses are commonly held liable for failing to keep an accurate count of sponges and other devices during surgery.

The best dietary sources of vitamin B6 are liver, kidney, pork, soybeans, corn, and whole-grain cereals.

Collaboration is joint communication and decision making between nurses and physicians. It’s designed to meet patients’ needs by integrating the care regimens of both professions into one comprehensive approach.

Bradycardia is a heart rate of fewer than 60 beats/minute.

A nursing diagnosis is a statement of a patient’s actual or potential health problem that can be resolved, diminished, or otherwise changed by nursing interventions.

During the assessment phase of the nursing process, the nurse collects and analyzes three types of data: health history, physical examination, and laboratory and diagnostic test data.

The patient’s health history consists primarily of subjective data, information that’s supplied by the patient.

The physical examination includes objective data obtained by inspection, palpation, percussion, and auscultation.

When documenting patient care, the nurse should write legibly, use only standard abbreviations, and sign each entry. The nurse should never destroy or attempt to obliterate documentation or leave vacant lines.

Factors that affect body temperature include time of day, age, physical activity, phase of menstrual cycle, and pregnancy.

The most accessible and commonly used artery for measuring a patient’s pulse rate is the radial artery. To take the pulse rate, the artery is compressed against the radius.

In a resting adult, the normal pulse rate is 60 to 100 beats/minute. The rate is slightly faster in women than in men and much faster in children than in adults.

Laboratory test results are an objective form of assessment data.

The measurement systems most commonly used in clinical practice are the metric system, apothecaries’ system, and household system.

Before signing an informed consent form, the patient should know whether other treatment options are available and should understand what will occur during the preoperative, intraoperative, and postoperative phases; the risks involved; and the possible complications. The patient should also have a general idea of the time required from surgery to recovery. In addition, he should have an opportunity to ask questions.

A patient must sign a separate informed consent form for each procedure.

During percussion, the nurse uses quick, sharp tapping of the fingers or hands against body surfaces to produce sounds. This procedure is done to determine the size, shape, position, and density of underlying organs and tissues; elicit tenderness; or assess reflexes.

Ballottement is a form of light palpation involving gentle, repetitive bouncing of tissues against the hand and feeling their rebound.

A foot cradle keeps bed linen off the patient’s feet to prevent skin irritation and breakdown, especially in a patient who has peripheral vascular disease or neuropathy.

Gastric lavage is flushing of the stomach and removal of ingested substances through a nasogastric tube. It’s used to treat poisoning or drug overdose.

During the evaluation step of the nursing process, the nurse assesses the patient’s response to therapy.

Bruits commonly indicate life- or limb-threatening vascular disease.

O.U. means each eye. O.D. is the right eye, and O.S. is the left eye.

To remove a patient’s artificial eye, the nurse depresses the lower lid.

The nurse should use a warm saline solution to clean an artificial eye.

A thready pulse is very fine and scarcely perceptible.

Axillary temperature is usually 1° F lower than oral temperature.

After suctioning a tracheostomy tube, the nurse must document the color, amount, consistency, and odor of secretions.

On a drug prescription, the abbreviation p.c. means that the drug should be administered after meals.

After bladder irrigation, the nurse should document the amount, color, and clarity of the urine and the presence of clots or sediment.

After bladder irrigation, the nurse should document the amount, color, and clarity of the urine and the presence of clots or sediment.

Laws regarding patient self-determination vary from state to state. Therefore, the nurse must be familiar with the laws of the state in which she works.

Gauge is the inside diameter of a needle: the smaller the gauge, the larger the diameter.